Ohio Behavioral Health Admission Form
Client’s Medicaid/MACSIS/GOSH/SHARES ID:Date of First Contact: / Admission Date:
Are ALL the client's services COMPLETELY paid by Medicaid? Yes No
Level of care / Education Enrollment / Prior AOD treatment episodes with Any Agency
Pre-treatment
Non-intensive Outpatient
Intensive Outpatient
Day Treatment
Non-Medical Community Residential
Medical Community Residential
Ambulatory Detoxification
Sub-Acute Detoxification
Acute Detoxification
No Treatment Recommended
Not Applicable (MH Only) / K – 12th Grade
GED Classes
Vocational/Job Training
College
Other School; Adult Basic Ed., Literacy
Not Enrolled
Unknown
Education Type (MH Only, K-12th Enrollment)
Not Currently Enrolled as Student
Not Behaviorally Handicapped
Severe Behavioral Handicapped / 0 Previous Episodes
1 Previous Episodes
2 Previous Episodes
3 Previous Episodes
4 Previous Episodes
5 or More Previous Episodes
6 Unknown
Diagnosis type
DSMV
ICD 10
Consistent with assessment (AOD Only)?
Yes No If no, select reason below.
Agency Financial Constraints
Appropriate LOC not available
Undue Client Hardship
Other Specify: ______/ Employment Status / Mental Health History (AOD Only)
Full Time
Part Time
Sheltered
Unemployed but Actively Looking for Work
Homemaker
Student
Volunteer Worker
Retired
Disabled
Inmate in Jail/Prison/Corrections
Engaged in Residential/Hospitalization
Other not in Labor Force
Unknown / Select if MH problem in addition to AOD problem
Opioid Replacement Therapy
No
Yes
Unknown
Referred by
Individual (includes self-referral/family/friend)
AOD Care Provider
Mental Health Provider
Other Health Care Provider
School
Employer/EAP
Child Welfare Agency (i.e. CDJFS, CSBS)
Other Community Referral
Courts/Other Criminal Justice
Unknown
Mental Health Only
Prison
Forensic
Jail
Ohio Families and children first council
TASC
Courts/CJ Felony
Courts/CJ Municipal
Courts/CJ Juvenile / Number of Children in Household Under 18
Primary Diagnosis Code
Secondary Diagnosis Code
Primary Source of Income/Support
Wages/Salary Income
Family/Relative
Public Assistance
Retirement/Pension
Disability
Other
Unknown
None / Tertiary Diagnosis Code
Quaternary Diagnosis Code
Marital status / Living arrangements______
Independent Living (Own Home)
Homeless
Other’s Home
Residential Care
Respite Care
Foster Care
Crisis Care
Temporary Housing
Community Residence
Nursing Facility
License MR Facility
State MH/MR Institution
Hospital
Correctional Facility
Other
Unknown / Special Populations (Select all that apply)______
Severely Mentally Disabled
Alcohol/Other Drug Abuse
Forensic Legal Status
Mental Retardation/Developmentally Disabled
Deaf/Hearing Impaired
Blind/Sight Impaired
Physically Disabled
Speech Impaired
Physical Abuse Victim
Sexual Abuse Victim
Domestic Violence Victim/Witness
Child of Alcohol/Drug Abuser
HIV/AIDS
Suicidal
Language barriers/English Second Language
Hepatitis C
Transgender
Client Custody of (or placed by) ODJFS/Children’s Service
Single/Never Married
Married/Living Together as Married
Divorced
Widowed
Separated
Unknown
Educational Level Completed
< 1st Grade
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade / High School Diploma
/GED
Some College
2 Yr. College/
Assoc. Degree
4 Yr. College/
Assoc. Degree
Masters/Doctorate/
Other Profession
Technical School
Unknown
Additional Client Information (Female Only) / Military status (Check all that Apply)
Child Birth within the last 5 years?
Yes No______
Total Number of Births (live and still) / Stage of pregnancy (if Client is Pregnant)
1st Trimester
2nd Trimester
3rd Trimester
Unknown / None
Discharged
Active duty
Disabled Veteran
Available Drug Choices
Alcohol / Other Hallucinogens / Other Non-Barbiturate Sedatives or Hypnotics
Cocaine/Crack / Methamphetamines / Inhalants
Marijuana/Hashish / Other Amphetamines / Over-the-Counter Medications
Heroin / Other Stimulants / Nicotine
Non-prescription methadone / Benzodiazepines / Other Medications
Other Opiates and Synthetics / Other Non-Barbiturate Tranquilizers / Unknown
PCP / Barbiturates
No Drug of Choice
Primary Drug of Choice / Frequency of Use / Route of Administration
(Select from above) / No Use in the last Past Month / Oral
Smoking
Inhalation
Injection
Other
Unknown
1 – 3 Times in the Past Month
1 – 2 Time in the Past Week
(Age of first / 3 – 6 Time in the Past Week
Age of First Use / intoxication when / Daily
Alcohol drug choice) / Unknown
Secondary Drug of Choice / Frequency of Use / Route of Administration
(Select from above) / No Use in the last Past Month / Oral
1 – 3 Times in the Past Month / Smoking
1 – 2 Time in the Past Week / Inhalation
(Age of first / 3 – 6 Time in the Past Week / Injection
Age of First Use / intoxication when / Daily / Other
Alcohol drug choice) / Unknown / Unknown
Tertiary Drug of Choice / Frequency of Use / Route of Administration
(Select from above) / No Use in the last Past Month / Oral
1 – 3 Times in the Past Month / Smoking
1 – 2 Time in the Past Week / Inhalation
(Age of first / 3 – 6 Time in the Past Week / Injection
Age of First Use / intoxication when / Daily / Other
Alcohol drug choice) / Unknown / Unknown
Number of Arrests in the
Past 30 Days / Primary Reimbursement / Frequency of attendance at self-help programs in the 30 days prior to admission?
Self-Pay
Blue Cross/Blue Shield
Medicare
Medicaid
Other Government Payments
Worker’s Compensation
Other Health Insurance Companies
No Charge
Other Payment Source
No attendance in the past month
1-3 times in the past month
4-7 times in the past month
8-15 times in the past month
16-30 times in the past month
Some attendance in the past month, but frequency unknown
Unknown
Paying Board/Resident Board of Client
Revised 01/02/2018